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Trifluperazine Induced Blepharospasm – a Missed Diagnosis

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Trifluperazine Induced Blepharospasm – a Missed Diagnosis Case Report Annals of Clinical Case Reports Published: 24 Aug, 2016 Trifluperazine Induced Blepharospasm – A Missed Diagnosis Sood T1*, Tomar M2, Sharma A2 and Ravinder G3 1Department of Ophthalmology, Civil Hospital Sarkaghat, India 2Department of Ophthalmology, Indira Gandhi Medical College, India 3Department of Dermatology, Zonal Hospital Bilaspur, India Abstract Tardive dystonia is a class of “tardive” movement disorder caused by antipsychotics and is specified by reflex muscle contraction, which may be tonic, spasmodic, patterned, or repetitive. This neurological disorder most commonly occurs as the repercussion of long-term or high-dose use of antipsychotic drugs. Tardive dyskinesia uncommonly inculpates the muscles of eye closure. Blepharospasm is a kind of focal tardive dystonia distinguished by persistent intermittent or persistent closure of the eyelids. Blepharospasm is an uncommon, persistently disabling medical condition rendering patient functionally blind and occupationally handicapped .We hereby tend to report a case of trifluoperazine induced tardive blepharospasm. Case Presentation A 46-year male patient reported to eye opd with complaint of progressive difficulty in opening his eyes for last two years .On examination he was unable to open his eyes voluntarily, sometimes thrusting his head backwards or rubbing his brow with his fingers during these episodes. Past and family history revealed no psychiatric or neurological illness. No past history of any other psychiatric/medical/surgical illness could be elicited. On specifically asking about medication history, he gave history of trifluoperazine intake. Patient was diagnosed with schizophreniform disorder 3 years back and was on treatment since then. Initially, he was started with 5mg trifluoperazine in twice daily dosage which had to be increased to (15mg/day) within a month. He was kept on this maintenance dosage for 2 years. While OPEN ACCESS being treated with trifluoperazine after 1 year patient developed frequent and forceful blinking of his eyelids. He would blink his eyes about 35-40 times in a minute when exacerbated by bright light. *Correspondence: During this course he consulted many doctors for blepharospasm but no cause could be Tarun Sood, Department of established. Ophthalmology, Civil Hospital Sarkaghat, Himachal Pardesh, India, Vitals were found stable on examination. No other neurological deficit could be diagnosed Tel: 9418644853; other than the abnormal movements. Blood biochemistry, complete blood picture, ECG, EEG, E-mail: [email protected] and brain imaging were essentially normal. The patient had no prior personal or family history of Received Date: 15 Jul 2016 blepharospasm or any other movement disorders. Accepted Date: 21 Aug 2016 Visual Acuity (with correction) was 20/25 Right eye (OD) and 20/20 Left eye (OS) and Published Date: 24 Aug 2016 Extraocular Motility was Full in both eyes (OU). B/L/ Pupils were found reacting well to light OS, Citation: no RAPD OU. Intraocular Pressure was 15 mmHg OU. Confrontation Visual Fields were Full OU. Sood T, Tomar M, Sharma A, On External Examination presence of bilateral brow ptosis was noticed. Frequent spasms of Ravinder G. Trifluperazine Induced the orbicularis oculi muscles, procerus, corrugators were present bilaterally causing forcible eyelid Blepharospasm – A Missed Diagnosis. closure. Slit Lamp Examination revealed no abnormality .Dilated Funduscopic Examination Ann Clin Case Rep. 2016; 1: 1092. revealed Normal disc, macula, vessels, and periphery OU. Copyright © 2016 Sood T. This is an Discussion open access article distributed under the Creative Commons Attribution Blepharospasm is classified as a type of focal dystonia and has been reported to License, which permits unrestricted occur with atypical antipsychotics. Tardive syndrome (TS) is a group of hyperkinetic or use, distribution, and reproduction in hypokinetic movement disorders and sensory symptoms sharing the same pathophysiological any medium, provided the original work basis. The etiological theories and treatment strategies have been elucidated recently is properly cited. [1,2]. This report presents a case of trifluoperazine-induced tardive dystonia. Remedy Publications LLC., | http://anncaserep.com/ 1 2016 | Volume 1 | Article 1092 Sood T, et al. Annals of Clinical Case Reports - Ophthalmology Trifluoperazine is a phenothiazine antipsychotic with high affinity Lastly, both blepharospasm and tardive dyskinesia are difficult for D2 receptors relative to D1 receptors [3]. It has lesser propensity to treat. There is no systemic medication that works well for either to induce seizures than other antipsychotics and therefore it is condition [11]. considered a “good choice” in treatment of comorbid schizophrenia Conclusion and epilepsy [4]. Trifluoperazine results in a variety of adverse reactions including sedation and weight gain, but to a lesser degree It is very important to consider possibility of tardive other antipsychotics [5,6]. Other adverse effects include postural blepharospasm in a patient on trifluoperazine therapy. Patient must hypotension, constipation, parkinsonism, priapism, and sexual be referred to an ophthalmologist to look for possibility of tardive dysfunction [7,8]. Trifluoperazine has been known for its high blepharospasm in case suspicion arises. Attention must be paid to propensity to cause extrapyramidal side effects, such as tardive specific cause and appropriate management because blepharospasm dyskinesia and akathisia [9,10]. interferes with performance and enjoyment of day to day activities. By definition, tardive dyskinesia is a result of drug therapy. References Tardive dyskinesia is a movement disorder resulting from taking 1. Waln O, Jankovic J. An update on tardive dyskinesia: From phenomenology certain drugs, distinctively a class of drugs called neuroleptics. These to treatment. Tremor Other Hyperkinet Mov (N Y). 2013; 3. drugs effect the chemicals in the brain. One of the chemicals affected is dopamine, which has a pivotal character in control of movement. 2. Bhidayasiri R, Fahn S, Weiner WJ, Gronseth GS, Sullivan KL, Zesiewicz TA, et al. Evidence-based guideline: Treatment of tardive syndromes: The extended use of neuroleptics leads to some aadaption in the Report of the Guideline Development Subcommittee of the American motor system that steers production of involuntary movement. Since Academy of Neurology. 2013; 81: 463-469. these movements are produced as late effect of taking these drugs, the dyskinesia is called tardive, which means late. Once these movements 3. Owens DC. Meet the relatives: a reintroduction to the clinical pharmacology of “typical” antipsychotics. Advances in Psychiatric Treatment. 2012; 18: occur, they can be quite long-lasting and possibly permanent. Tardive 337–350. dyskinesias can affect any muscle in the body, but they very commonly affect cranial nerve muscles. The muscles affected commonly are 4. Hedges D, Jeppson K, Whitehead P. Antipsychotic medication and tongue, the jaw closing muscles, and the muscles around the mouth, seizures: a review. Drugs of Today. 2003; 39: 551–557. but eyelid closing muscles can also be affected. When eyelid closing 5. Marques LDO, Soares B, Silva de Lima M. Trifluoperazine for muscles are affected, there can be blinking or sustained closure of schizophrenia. Cochrane Database of Systematic Reviews. 2004; 1: the eyelids, which could mimick blepharospasm. Movements of the CD003545. tongue and lips are particularly emine Tardive Blepharospasm is 6. Taylor D, Paton C, Kapur S. The Maudsley Prescribing Guidelines. 10th worse in stress, fatigue, bright lights, watching television or driving, edition. chapter 7. London, UK: Informa Healthcare; 2009. and social interactions while Sleep, relaxation, walking, talking and 7. Bashford G, Bradd P. Drug-induced Parkinsonism associated with other "tricks" alleviate symptoms temporarily. dysphagia and aspiration: a brief report.Journal of Geriatric Psychiatry and Neurology. 1996; 9: 133–135. The early symptoms of blepharospasm include increased blink rate (77%), eyelid spasms (66%), eye irritation (55%), midfacial or 8. Barnes TR, Katona CL. Susceptibility to drug-induced hypotension in lower facial spasm (59%), brow spasm (24%), and eyelid tic (22%). nt post-partum psychosis.International Clinical Psychopharmacology. 1986; in tardive dyskinesia. These movements can also occur in rhythmic 1: 74–76. repetitive trains. 9. Sachdev P. Tardive blepharospasm. Movement Disorders. 1998; 13: 947– 951. Because both blepharospasm and tardive dyskinesia can cause blinking or sustained closure of the eyelids, their appearance can be 10. Chouinard G, Boisvert D, Bradwejn J. Tardive dyskinesia in a nonpsychiatric similar. However, tardive dyskinesia would only infrequently involve patient due to short-term use of a neuroleptic/anticholinergic combination drug. Canadian Medical Association Journal. 1982; 126: 821–827. the muscles of eye closure. Therefore, unless the focal dystonia in the patient with blepharospasm has spread to involve the rest of the face, 11. Benign Essential Blepharospasm Research Foundation Newsletter. 2012; it ordinarily would not be difficult on clinical grounds to separate 31. patients with blepharospasm and tardive dyskinesia. Remedy Publications LLC., | http://anncaserep.com/ 2 2016 | Volume 1 | Article 1092.
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